Until prescribing opiates abates, heroin will continue its deadly swath

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A heroin addict prepares drugs to shoot intravenously earlier this month in St. Johnsbury, Vt.

By Haider Javed WarraichGlobe Correspondent
February 19, 2014

The heroin epidemic in Taunton — 64 overdoses since the year began, five fatally — has brought the city to its knees. And yet Taunton is just one of many communities in New England ravaged by this illicit substance. A few days ago, I was consoling the fiancee of a young man who had arrived at the intensive care unit at a Brockton hospital. She found him in the morning on the bathroom floor, unresponsive. She called 911; responders arrived and shocked his heart to life, but could do nothing about the fact that his brain had not seen oxygen for close to an hour. He was brain dead. “He was clean for more than a year,’’ she told me. “He had a good job, a stable relationship.” She was shocked as to why he would go back to the drug.

These days when a young person comes to an ICU after a cardiac arrest, it is usually after a drug overdose, particularly heroin. Growing up in Pakistan, a country bordering the world’s largest producer of heroin, Afghanistan, I was accustomed to seeing patients die from heroin overdoses. However, I was not ready for the heroin epidemic in the United States. Just in the past decade, the number of people getting addicted to heroin has increased by 60 percent even as the uptake of cocaine, methamphetamine, and crack dropped, according to the National Survey on Drug Use and Health. In Massachusetts, State Police report an increase in usage in every county. Heroin and opiate overdoses are the greatest killers of homeless people in Boston, according to a study published in JAMA Internal Medicine. In Maine, according to the governor’s office, 7 percent of babies are born addicted to opiates. The governor of Vermont dedicated his entire State of the State address to the heroin crisis there.

There has also been an increase in the incidence of heroin tainted with other substances. I recently managed a patient who had heroin cut with clenbuterol, which has toxic effects that are the opposite of heroin’s effects. While heroin depresses the body’s systems, clenbuterol accelerates the heart and other organs, making a diagnosis extremely difficult.

But the roots of this crisis are clear: The heroin epidemic is strongly related to the spread of prescription drug abuse. Drugs like Oxyontin, Dilaudid, and Percocet are opiate-containing narcotic medications, and act on the same mu-receptor that heroin does. However, while the street value of these prescription drugs is quite high, heroin remains inexpensive. Thus people who get hooked on prescription drugs may end up resorting to heroin.

Prescription opiate use has skyrocketed over the past two decades, with about 39 percent of most opiates being prescribed in emergency rooms. New York City has passed strict restrictions on opiate prescriptions in emergency rooms, but such restrictions do not exist in most states, including Massachusetts. This needs to change.

Physicians walk a narrow path between controlling pain and spreading opiate addiction. While opiates are certainly not the only painkillers available, they are considered more potent. Physicians are frequently pressured by patients to prescribe opiates, and increased focus on patient satisfaction is driving physicians to aggressively treat pain with powerful medications. In fact, doctors working at Veterans Affairs hospitals testified to House lawmakers in October 2013 about being pressured by hospital administrators to prescribe opiates to veterans. While doctors commonly use a 10-point scale to assess pain, a 2005 study published in Anesthesia and Analgesia showed that implementation of that scale, while improving patient satisfaction, resulted in a more than two-fold increase in opiate-related adverse events. But anyone who has ever practiced medicine knows that being judicious with opiate use is always easier said than done because of the thin line between being pain-free and being over-sedated.

Doctors need more protection, both from administrators as well as from regulators, to avoid prescribing potentially harmful drugs. Non-opiate options for pain relief, particularly in patients with chronic pain, need to be better researched and made available. A more open electronic system of health records would help physicians track opiate abusers who have been doctor shopping, ensuring they treat pain and not abet addiction. Most importantly, patients need to think long and hard about just how aggressively they want to treat their pain and whether they would want to be prescribed opiates.

A young man, found on the verge of unconsciousness by his ex-wife, was brought into the emergency room few weeks ago. Even after he got intravenous naloxone, the antidote for opiates, he would breathe only a few times a minute. What was scary was that a $20 bag of heroin had almost killed a seasoned user. When he woke up a bit more, he requested to be discharged from the hospital. While I initially felt frustrated, I was soon filled with a mountain of sorrow. With pupils thinner than a needle’s eye, he told me that he had to make it to his daughter’s recital.

There are few things that can destroy lives and are as purely evil as heroin. At a time when social attitudes about drug use are in flux, it must not be forgotten how heroin can destroy the foundations of communities, sapping the hearts of its young men and women. More is needed to eradicate this dark substance.

Haider Javed Warraich is a resident in internal medicine at the Beth Israel Deaconess Medical Center.